Mental Health Policy in Ireland: A Decade after A Vision for Change, Where Are We Now?

BD Kelly

In 2006, the Irish government published A Vision for Change: Report of the Expert Group on Mental Health Policy, a comprehensive mental health policy document which sought to consolidate and deepen moves towards community-based mental health care in Ireland.1,2 Did it work?

Long before A Vision for Change was published, there was already a well-established commitment to community mental health care, dating from The Psychiatric Services: Planning for the Future (1984)3 and even the 1967 Commission of Enquiry on Mental Illness4 which recommended "radical and widespread changes" (p.xv), moving away from "barrack-like structures characterised by large wards, gloomy corridors and stone stairways" (p.xiii) and towards the provision of community care. As a result, well before A Vision for Change appeared in 2006, there was a strong emphasis on community care, at least in certain parts of the country, as reflected in the reduction of the number of "mentally ill" persons in institutions from 18,188 in 1966 to 4,522 in 2000.5

Since 2006, however, the rate of implementation of A Vision for Change has been commonly criticised as being too slow. In 2008, one study of 32 mental health services reported that just 16% of services had received the resources promised in order to implement the new policy; 32% had not been promised such resources and nor was there tangible evidence of the requisite enhancement of clinical teams; and there was significant concern about low levels of recruitment to multidisciplinary teams.6 In September 2009, a report by Indecon International Consultants, submitted to Amnesty International, made some similar points, highlighting that while definite progress had been made, significant deficits remained in relation to the number of community mental health teams and their composition.7 The report also pointed to an over-reliance on traditional acute and long-stay inpatient facilities, and presented a series of recommendations for future development of services, including setting new, realistic implementation targets. The rate of implementation was also a key concern of the Independent Monitoring Group (IMC) established as part of A Vision for Change in March 2006.8 In June 2012, the IMC, in its sixth annual report, concluded that implementation of the policy was still "slow and inconsistent" (p.3). The IMC pointed in particular to the "continued absence of a National Mental Health Service Directorate with authority and control of resources. Such a body has the potential to give strong corporate leadership and act as a catalyst for change".

On a more positive note, there was "evidence of many local and regional initiatives being developed in line with [A Vision for Change]. These are principally 'bottom-up' developments led by local leadership". Nonetheless, there was still much to be done. Many of the same themes recurred in a further, independent study of implementation published in 2014, which identified a significant body of opinion that saw implementation as slow, haphazard and uneven.9 This study identified a need for authoritative, accountable leadership as a key factor for implementation and, in 2013, the HSE duly appointed a National Director for Mental Health. The HSE Mental Health Division now has responsibility for all HSE mental health services. In addition, the National Clinical Programme for Mental Health was set up in 2010, in collaboration with the College of Psychiatrists of Ireland, to standardise high quality evidence-based practice across mental health services in relation to (a) management of patients presenting to emergency departments following self-harm; (b) early intervention for people developing first episode psychosis; and (c) eating disorders. While change of this magnitude is invariably complex, significant progress has been reported in several areas with, for example, 23 of the 35 posts identified to address self-harm in Emergency Departments in place by March 2015, and the remainder in the recruitment process.

Notwithstanding these positive developments, challenges remain in relation to A Vision for Change. In 2014, the Chairman of the Mental Health Commission10 pointed to some of the key issues: "The implementation of policy to date is still reliant on innovative and imaginative clinical and administrative leadership at regional and local levels. There is considerable commitment to the policy. Despite these actions the policy is being implemented unevenly and inconsistently across the country and there is a requirement for innovative actions to be supported and reinforced by strong corporate governance at national level" (p.6).

While acknowledging recent progress in relation to governance, budgetary assurances, physical infrastructure and certain other areas, the Commission was still "concerned regarding a number of specific areas of service provision which impinge on human rights and where, in 2013, standards fell below what is acceptable" (p.7). These areas included individualised care plans (implemented appropriately in an estimated 60% of approved centres), unacceptable use of seclusion and restraint, continued admission of children to adult facilities (22.3% of all child admissions in 2013), the absence of reformed, enacted mental capacity legislation, and various issues relating to staffing. Clearly, the decade since A Vision for Change was published has seen substantial progress. Equally clearly, however, the next decade needs to see further progress if the Vision is to be finally, fully realised.

6. Barry S, Murphy P (on behalf of the Faculty of Clinical Directors of the College of Psychiatry of Ireland). A Gloomy View: Rhetoric or Reality in Relation to the Advancement of A Vision for Change. Dublin: College of Psychiatry of Ireland, 2009.

7. Indecon International Consultants. Review of Government Spending on Mental Health and Assessment of Progress on Implementation of A Vision for Change. Dublin: Indecon/Amnesty International, 2009.

9. Johnston H. All Vision but No Change? Determinants of Implementation: The Case of Ireland and Mental Health Policy (Issues in Public Administration). Dublin: Institute of Public Administration, 2014.